Saturday, July 23, 2016

Fentanyl and Other Super-Opioids

I’ve seen media reports of big heroin shipment seizures.
There are pictures of wooden pallets holding several kilograms, even a ton or
so, of pure heroin. Police dressed like
soldiers, with assault rifles and armored vests, stand guarding it. And I
think, this is why the drug war is unwinnable:

“Fentanyl is estimated to have 50 times the potency as pure,
pharmacy-grade heroin and about 100 times the potency of morphine.”

Fentanyl isn’t even the most potent opioid. Sufentanil is 5-
to 10-times stronger still (yes, the stuff that Jessica Jones used to knock out
Purple Man), and there are even more powerful opioids than that:

“In mouse studies, the most active isomer
3R,4S,βS-ohmefentanyl was 28 times more powerful as a painkiller than fentanyl,
the chemical from which it is derived, and 6300 times more effective than
morphine.

…

The 4"-fluoro analogue (i.e. substituted on the
phenethyl ring) of the 3R,4S,βS isomer of ohmefentanyl is one of the most
potent opioid agonists yet discovered, possessing an analgesic potency
approximately 18,000-fold greater than morphine.[9] Other analogues with
potency higher than that of ohmefentanyl itself include the 2'-fluoro
derivative (i.e. substituted on the aniline phenyl ring), and derivatives where
the N-propionyl group was replaced by N-methoxyacetyl or 2-furamide groups, or
a carboethoxy group is added to the 4-position of the piperidine ring. The
latter is listed as being up to 30,000 times more potent than morphine.”

Emphasis added. By which I mean, "I read this and said to myself 'Holy shit!'" Reduce that giant
shipment spread out across all those wooden pallets to a 1-pound package, which
can easily hide in some dark corner of a shipping container or carry-on luggage
on an airplane or trunk of an automobile. Before it’s sold to the user it gets
cut by amateurs who don’t know what they’re doing, and a bad batch might poison
a dozen people. This is already becoming a huge problem, and it’s showing up in
the drug poisoning statistics. Notice how the Heroin and Fentanyl deaths (the fat red and blue lines) are
spiking in very recent years. I actually suspect there’s some cross-over. Some “heroin”
overdoses are really bad batches mixed with fentanyl, but not every locality is
super diligent about checking what exact substance killed a person. (Caveat: There isn’t
actually a “fentanyl” code for drug overdoses in ICD-10; there’s one for “other
synthetic narcotics” which covers fentanyl and a few others.)

There are ways to reduce the number of overdoses and there
are ways to reduce the harm caused by opioid abuse, but none of them are
possible in the midst of a drug war. We need to legalize drugs if we ever want
to achieve any degree of real harm reduction. Keep hammering dealers, and
someone will invent something 1000 times as strong as fentanyl and will smuggle
the nation’s annual supply into the country in a single briefcase. OR we could
just give addicts legal access to safe, pharmaceutical-quality heroin, free of adulterants and in a known dosage with a clean needle. Opioid
addiction doesn’t cause the kind of cumulative organ damage that, say, alcohol
or cocaine use does to your body, and most addicts eventually “mature out” of
their addiction in a decade or so. If we can keep these people from overdosing,
they will mature out of their addictions without any long-term serious health
issues. That’s what drug policy should strive for: reduce overdose deaths and
mitigate harms to health. The United States has chosen a drug policy that does
the opposite. Take a look at those spiking overdose deaths in the chart above. If you favor drug prohibition, if you oppose legalization, you've effectively asked for this.